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Official Website of the Department of Homeland Security
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APPLICATION NUMBER:
APPLICANT INFORMATION
Family Name
First (Given) Name
Passport Number
Issuing Country
Issuance Date
Expiration Date
Country of Citizenship / Nationality
National Identification Number
Personal Identification Number
Gender
Date of Birth
City of Birth
Country of Birth
OTHER CITIZENSHIP / NATIONALITY
Are you now, a citizen or national of any other country?
Have you ever been a citizen or national of any other country?
E-mail Address
Confirm E-mail Address
PERSONAL INFORMATION
Are you known by any other names or aliases?
Have you ever been issued a passport or national identity card for travel by any other country?
YOUR CONTACT INFORMATION
Address Line 1
Address Line 2
Apartment Number
City
State/Province/Region
Country
SOCIAL MEDIA(Optional)
N/A
GE/NEXUS/SENTRI MEMBERSHIP
Are you a member of the CBP Global Entry/NEXUS/SENTRI Program?
PARENTS
Parent 1 Family Name
Parent 1 First (Given) Name
Parent 2 Family Name
Parent 2 First (Given) Name
EMPLOYMENT INFORMATION
Do you have a current or previous employer?
TRAVEL INFORMATION
Is your travel to the US occurring in transit to another country?
EMERGENCY CONTACT INFORMATION IN OR OUT OF THE U.S.
Family Name
First (Given) Name
Email Address
Phone Country Code
Phone Number
ELIGIBILITY QUESTIONS
1) Do you have a physical or mental disorder; or are you a drug abuser or addict; or do you currently have any of the following diseases (communicable diseases are specified pursuant to section 361(b) of the Public Health Service Act):
2) Have you ever been arrested or convicted for a crime that resulted in serious damage to property, or serious harm to another person or government authority?
3) Have you ever violated any law related to possessing, using, or distributing illegal drugs?
4) Do you seek to engage in or have you ever engaged in terrorist activities, espionage, sabotage, or genocide?
5) Have you ever committed fraud or misrepresented yourself or others to obtain, or assist others to obtain, a visa or entry into the United States?
6) Are you currently seeking employment in the United States or were you previously employed in the United States without prior permission from the U.S. government?
7) Have you ever been denied a U.S. visa you applied for with your current or previous passport, or have you ever been refused admission to the United States or withdrawn your application for admission at a U.S. port of entry?
8) Have you ever stayed in the United States longer than the admission period granted to you by the U.S. government?
